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TRICARE Systems Manual 7950.3-M, April 1, 2015
TRICARE Encounter Data (TED)
Chapter 2
Section 6.4
Non-Institutional Edit Requirements (ELN 300 - 399)
Revision:  C-29, September 20, 2019
ELEMENT NAME:  ENROLLMENT/HEALTH PLAN CODE (2-300)
1  PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.
VALIDITY EDITS
2-300-01V
MUST BE A VALID ENROLLMENT/HEALTH PLAN CODE (REFER TO Section 2.5)
Relational Edits
2-300-02R
IF ENROLLMENT/HEALTH PLAN CODE =
Y
CHCBP - NON-NETWORK OR
AA
CHCBP - NETWORK
THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE =
CL
CLINICAL TRIALS OR
PF
ECHO
2-300-07R
IF ENROLLMENT/HEALTH PLAN CODE =
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
ST
SHCP - TRICARE ELIGIBLE
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AN
SHCP -NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
2-300-10R
IF ENROLLMENT/HEALTH PLAN CODE =
PS
TSRx
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-300-11R
IF ENROLLMENT/HEALTH PLAN CODE =
PS
TSRx
THEN NATIONAL DRUG CODE CANNOT BE BLANK.
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE FOR THAT OCCURRENCE/LINE ITEM = ZERO
OR ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
1
MEDICAID
OR PROVIDER STATE OR COUNTRY CODE IS FOREIGN COUNTRY CODE (Addendum A)
2-300-12R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
FOR EACH LINE ITEM WHERE BEGIN DATE OF CARE IS < 10/01/2001, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
IF ENROLLMENT/HEALTH PLAN CODE =
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK
THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
ELSE IF BEGIN DATE OF CARE IS < 10/01/2001 (FOR THAT DETAILED LINE ITEM)
THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE MUST =
15
PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
26
EXPENSES INCURRED PRIOR TO COVERAGE OR
27
EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
30
PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
31
CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
32
OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
33
CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
34
CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
62
PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
141
CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
2-300-15R
IF ENROLLMENT/HEALTH PLAN CODE =
SU
SCHP - REFERRAL DESIGNATION UNKNOWN
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
2-300-16R
IF ENROLLMENT/HEALTH PLAN CODE =
SU
SCHP - REFERRAL DESIGNATION UNKNOWN
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE
2-300-17R
•  FOR MOP ONLY: FOR TSRx, THE PATIENT MUST BE 64 YEARS AND 8 MONTHS OR GREATER. IF THE PATIENT IS LESS THAN THIS AGE, THE LINE ITEM MUST CONTAIN AN ADJUSTMENT/DENIAL REASON CODE LISTED IN THIS EDIT.
IF ENROLLMENT/HEALTH PLAN CODE =
PS
TSRx
AND TYPE OF SERVICE (SECOND POSITION) =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
THEN PATIENT AGE1 MUST BE ≥ 64 YEARS AND 8 MONTHS
ELSE IF PATIENT AGE1 < 64 YEARS AND 8 MONTHS
THEN ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE MUST =
15
PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
26
EXPENSES INCURRED PRIOR TO COVERAGE OR
27
EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
30
PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
31
CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
32
OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
33
CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
34
CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
62
PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
141
CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
2-300-18R
IF ENROLLMENT/HEALTH PLAN CODE =
X
FOREIGN SERVICE MEMBER
THEN HCC MEMBER RELATIONSHIP CODE MUST =
A
SELF OR
T
FOREIGN MILITARY MEMBER
AND HCC MEMBER CATEGORY CODE MUST =
A
ACTIVE DUTY OR
G
NATIONAL GUARD MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
J
ACADEMY STUDENT OR
N
NATIONAL GUARD (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS) OR
S
RESERVE MEMBER (MOBILIZED OR ON ACTIVE DUTY FOR 31 DAYS OR MORE) OR
V
RESERVE MEMBER (NOT ON ACTIVE DUTY OR ON ACTIVE DUTY FOR 30 DAYS OR LESS)
2-300-19R
IF BEGIN DATE OF CARE IS ≥ 01/01/2018
AND ENROLLMENT/HEALTH PLAN CODE =
ME
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
MS
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK
THEN AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
R
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
ELEMENT NAME:  HEALTH CARE DELIVERY PROGRAM (HCDP) PLAN COVERAGE CODE (2-301)
VALIDITY EDITS
2-301-01V
MUST BE A VALID HCDP PLAN COVERAGE CODE LISTED IN Addendum L.
2-301-02V
IF FILING DATE ≥ 09/01/2007
AND HCDP PLAN COVERAGE CODE =
109
TRICARE USFHP DIRECT CARE COVERAGE FOR ADFMs OR
114
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
115
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
118
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
119
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR RETIRED SPONSORS AND FAMILY MEMBERS OR
133
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR TRANSITIONAL SURVIVORS OR ACTIVE DUTY DECEASED SPONSORS OR
138
TRICARE USFHP DIRECT CARE INDIVIDUAL COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
139
TRICARE USFHP DIRECT CARE FAMILY COVERAGE FOR SURVIVORS OF GUARD/RESERVE DECEASED SPONSORS OR
316
USFHP PRIME - SPONSOR AND FAMILY MEMBERS (PRESENTATION ONLY)
THEN THE TOTAL OF ALL OCCURRENCES/LINEITEMS OF AMOUNT ALLOWED BY PROCEDURE CODES MUST = ZERO
2-301-03R
IF HCDP PLAN COVERAGE CODE =
417
TCSRC
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
X
FOREIGN SERVICE MEMBER OR
SR
SHCP - MTF/eMSM REFERRED CARE
Relational Edits
2-301-01R
IF HCDP PLAN COVERAGE CODE =
306
TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
307
TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
401
TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR
402
TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
405
TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR
406
TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
407
TRS TIER 3 MEMBER-ONLY COVERAGE (SERVICE AGREEMENT) OR
408
TRS TIER 3 MEMBER AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
409
TRS SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
410
TRS SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
411
TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR
412
TRS SURVIVOR NEW FAMILY COVERAGE OR
413
TRS MEMBER-ONLY COVERAGE OR
414
TRS MEMBER AND FAMILY COVERAGE OR
418
TRICARE RETIRED RESERVE (TRR) MEMBER-ONLY COVERAGE OR
419
TRR MEMBER AND FAMILY COVERAGE OR
420
TRR SURVIVOR INDIVIDUAL COVERAGE OR
421
TRR SURVIVOR FAMILY COVERAGE
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
T
TRICARE STANDARD OR
V
TRICARE EXTRA OR
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK OR
ME
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
MS
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON NETWORK OR
PS
TSRx OR
SR
SHCP-MTF/eMSM REFERRED CARE OR
TV
TRICARE SELECT
2-301-02R
IF HCDP PLAN COVERAGE CODE =
305
TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
306
TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
307
TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
401
TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR
402
TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
405
TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR
406
TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
407
TRS TIER 3 MEMBER-ONLY COVERAGE (SERVICE AGREEMENT) OR
408
TRS TIER 3 MEMBER AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
409
TRS SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
410
TRS SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
411
TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR
412
TRS SURVIVOR NEW FAMILY COVERAGE OR
413
TRS MEMBER-ONLY COVERAGE OR
414
TRS MEMBER AND FAMILY COVERAGE OR
418
TRR MEMBER-ONLY COVERAGE OR
419
TRR MEMBER AND FAMILY COVERAGE OR
420
TRR SURVIVOR INDIVIDUAL COVERAGE OR
421
TRR SURVIVOR FAMILY COVERAGE
THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE CAN =
PF
ECHO
ELEMENT NAME:  REGION INDICATOR (2-303)
VALIDITY EDITS
2-303-01V
MUST BE A VALID REGION INDICATOR (REFER TO Section 2.8)
2-303-02V
IF TYPE OF SUBMISSION ≠
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA
AND REGION INDICATOR =
NC
NORTH CONTRACT OR
OC
OVERSEAS CONTRACT OR
SC
SOUTH CONTRACT OR
WC
WEST CONTRACT OR
E7
EAST CONTRACT 2017 OR
W7
WEST CONTRACT 2017
THEN ADJUSTMENT KEY MUST =
0
BATCH OR
5
VOUCHER
Relational Edits
NONE
ELEMENT NAME:  SPECIAL PROCESSING CODE (2-305)
1  PATIENT AGE IS CALCULATED BASED ON PERSON BIRTH CALENDAR DATE (PATIENT) AND CARE DATES.
VALIDITY EDITS
2-305-01V
OCCURRENCE NUMBER 1--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8)
2-305-02V
OCCURRENCE NUMBER 2--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8)
2-305-03V
OCCURRENCE NUMBER 3--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8)
2-305-04V
OCCURRENCE NUMBER 4--MUST BE A VALID SPECIAL PROCESSING CODE (REFER TO Section 2.8)
2-305-05V
A VALUE CANNOT BE CODED MORE THAN ONCE (EXCEPT BLANK).
2-305-06V
ALL OCCURRENCES OF SPECIAL PROCESSING CODE MUST BE BLANK FILLED FOLLOWING THE FIRST OCCURRENCE OF A BLANK FILLED SPECIAL PROCESSING CODE.
2-305-07V
•  SHCP - MTF/eMSM REFERRED/NON-REFERRED
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE
THEN BEGIN DATE OF CARE MUST BE < 06/01/2004
2-305-08V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
GF
TPR FOR ELIGIBLE ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
THEN BEGIN DATE OF CARE MUST BE < 09/01/2002
2-305-10V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
MN
TSP - NON-NETWORK OR
MS
TSP - NETWORK
THEN BEGIN DATE OF CARE MUST BE < 12/31/2001
2-305-11V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
SN
TSS - NON-NETWORK OR
SS
TSS - NETWORK
THEN BEGIN DATE OF CARE MUST BE < 12/31/2002
2-305-14V
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
ST
SPECIALIZED TREATMENT
THEN BEGIN DATE OF CARE MUST BE < 10/01/2004
Relational Edits
2-305-02R
IF CA/NAS EXCEPTION REASON =
6
RESOURCE SHARING
THEN AT LEAST ONE SPECIAL PROCESSING CODE MUST =
S
RESOURCE SHARING - EXTERNAL
2-305-08R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PF
ECHO
THEN NO OCCURRENCE OF SPECIAL PROCESSING CODE =
6
HHC OR
A
PARTNERSHIP PROGRAM OR
E
HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP) OR
S
RESOURCE SHARING - EXTERNAL OR
CM
ICMP OR
CT
CCTP OR
RI
RESOURCE SHARING - INTERNAL
2-305-12R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
U
BRAC MEDICARE PHARMACY
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
AND BEGIN DATE OF CARE MUST BE < 04/01/2001
2-305-13R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
16
AMBULATORY SURGERY FACILITY CHARGE
THEN PRICING RATE CODE MUST =
0
PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS) OR
1
PRICED MANUALLY OR
C
AMBULATORY SURGERY FACILITY PAYMENT RATE OR
D
DISCOUNTED AMBULATORY SURGERY - FACILITY PAYMENT RATE OR
E
AMBULATORY SURGERY-PAID AS BILLED OR
P
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
Q
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
R
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED OR
V
MEDICARE REIMBURSEMENT RATE OR
CA
CAH REIMBURSEMENT OR
P1
OPPS OR
P2
OPPS WITH COST OUTLIER OR
P3
OPPS WITH DISCOUNT
2-305-14R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PO
TRICARE PRIME - POS
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
U
TRICARE PRIME, CIVILIAN PCM OR
Z
TRICARE PRIME, MTF/eMSM/PCM OR
WF
TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER OR
XF
FOREIGN ADFM
2-305-22R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SO
SHCP - NON-TRICARE ELIGIBLE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
ST
SHCP - TRICARE ELIGIBLE OR
SU
SHCP - REFERRAL DESIGNATION UNKNOWN
2-305-24R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
E
HHC/CM DEMO (AFTER 03/15/1999, GRANDFATHERED INTO THE ICMP)
THEN BEGIN DATE OF CARE MUST BE ≥ 03/15/1999
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
CM
ICMP
2-305-26R
•  TFL CLAIMS: THE BEGIN DATE OF CARE MUST BE ≥ 10/01/2001.
IF AMOUNT ALLOWED BY PROCEDURE CODE IS ≤ ZERO
THEN BYPASS THIS EDIT
ELSE ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
FF
TFL (FIRST PAYOR-NOT A MEDICARE BENEFIT) OR
FG
TFL (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICAL BENEFITS HAVE BEEN EXHAUSTED) OR
FS
TFL (SECOND PAYOR)
THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2001
AND ENROLLMENT/HEALTH PLAN CODE MUST =
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK
2-305-30R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PF
ECHO
THEN HCDP PLAN COVERAGE CODE MUST ≠
305
TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
306
TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
307
TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
401
TRS TIER 1 MEMBER-ONLY COVERAGE (CONTINGENCY OPERATIONS) OR
402
TRS TIER 1 MEMBER AND FAMILY COVERAGE (CONTINGENCY OPERATIONS) OR
405
TRS TIER 2 MEMBER-ONLY COVERAGE (CERTIFIED QUALIFICATIONS) OR
406
TRS TIER 2 MEMBER AND FAMILY COVERAGE (CERTIFIED QUALIFICATIONS) OR
407
TRS TIER 3 MEMBER-ONLY COVERAGE (SERVICE AGREEMENT) OR
408
TRS TIER 3 MEMBER AND FAMILY COVERAGE (SERVICE AGREEMENT) OR
409
TRS SURVIVOR CONTINUING WITH INDIVIDUAL COVERAGE OR
410
TRS SURVIVOR CONTINUING WITH FAMILY COVERAGE OR
411
TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR
412
TRS SURVIVOR NEW FAMILY COVERAGE OR
413
TRS MEMBER-ONLY COVERAGE OR
414
TRS MEMBER AND FAMILY COVERAGE OR
418
TRR MEMBER-ONLY COVERAGE OR
419
TRR MEMBER AND FAMILY COVERAGE OR
420
TRR SURVIVOR INDIVIDUAL COVERAGE OR
421
TRR SURVIVOR FAMILY COVERAGE
2-305-31R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AU
AUTISM DEMONSTRATION
THEN BEGIN DATE OF CARE MUST BE ≥ 03/15/2008
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
PF
ECHO
AND PATIENT AGE1 MUST BE ≥ 18 MONTHS
2-305-32R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
RB
RESPITE BENEFIT FOR ADSMS
THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2008
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
SE
SHCP - TRICARE ELIGIBLE
2-305-33R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PS
SPECIALTY PHARMACY SERVICES
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
AND PROCEDURE CODE MUST ≠
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
2-305-34R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PV
RETAIL PHARMACY FOR DVA/VHA BENEFICIARIES
THEN TYPE OF SERVICE (SECOND POSITION) MUST =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
AND PROVIDER NETWORK STATUS INDICATOR MUST =
1
NETWORK PROVIDER
AND PROCEDURE CODE MUST ≠
000MN
PRESCRIPTION MEDICAL NECESSITY REVIEWS OR
000PA
PRESCRIPTION PRIOR AUTHORIZATIONS
2-305-35R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
DE
TDRL PHYSICAL EXAMS
THEN BEGIN DATE OF CARE MUST BE ≥ 03/30/2009
AND ENROLLMENT/HEALTH PLAN CODE MUST =
SR
SHCP - MTF/eMSM REFERRED CARE
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
SE
SHCP - TRICARE ELIGIBLE
2-305-36R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
EF
TRICARE RESERVE AND NATIONAL GUARD FAMILY MEMBER BENEFITS
THEN BEGIN DATE OF CARE MUST BE ≥11/01/2009
AND ENROLLMENT/HEALTH PLAN CODE MUST =
T
TRICARE STANDARD PROGRAM OR
V
TRICARE EXTRA OR
TV
TRICARE SELECT OR
ME
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
MS
MEDICARE/TRICARE DUAL ELIGIBILE UNDER 65/NON-NETWORK
AND HCDP SPECIAL ENTITLEMENT CODE MUST =
02
NOBLE EAGLE PARTICIPATION SPECIAL ENTITLEMENT OR
03
ENDURING FREEDOM PARTICIPATION SPECIAL ENTITLEMENT OR
08
SPECIAL ENTITLEMENT FOR GUARD/RESERVE ON ACTIVE DUTY MORE THAN 30 DAYS (EXCL. AGR)
AND AMOUNT APPLIED TOWARD DEDUCTIBLE MUST = ZERO
2-305-37R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
DC
DCPE-VHA
THEN BEGIN DATE OF CARE MUST BE ≥ 10/01/2014
AND AT LEAST ONE OTHER OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
17
VHA MEDICAL PROVIDER CLAIM OR
AD
FOREIGN ACTIVE DUTY CLAIMS
AND ENROLLMENT/HEALTH PLAN CODE MUST =
W
TPR SERVICE MEMBER - USA OR
X
FOREIGN SERVICE MEMBER OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WA
TPR FOREIGN SERVICE MEMBER
AND AT LEAST ONE PROCEDURE CODE MUST = 99456
OR PRINCIPLE DIAGNOSIS CODE MUST = V68.01 OR Z02.71
2-305-38R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
PH
PHILIPPINES DEMONSTRATION PROJECT
THEN BEGIN DATE OF CARE MUST BE ≥ 01/01/2013
AND HCDP PLAN COVERAGE CODE MUST =
003
TRICARE STANDARD FOR ADFMs OR
005
TRICARE STANDARD SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
007
TRICARE STANDARD TRANSITIONAL ASSISTANCE SPONSORS AND FAMILY MEMBERS OR
009
TRICARE STANDARD RETIRED AND MOH SPONSORS AND FAMILY MEMBERS OR
010
TRICARE STANDARD TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
015
TRICARE STANDARD TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
017
TRICARE STANDARD SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
018
TFL RETIRED SPONSORS AND FAMILY MEMBERS AND MOH OR
020
TFL TRANSITIONAL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
021
TFL SURVIVORS OF ACTIVE DUTY DECEASED SPONSORS OR
022
TFL TRANSITIONAL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
023
TFL SURVIVORS OF NG/RESERVE DECEASED SPONSORS OR
028
TRICARE STANDARD FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
029
TFL FOR MEDICALLY RETIRED SPONSORS AND FAMILY MEMBERS OR
303
TRICARE SELECT - ADFMs OR
304
TRICARE SELECT - TAMP SPONSORS AND FAMILY MEMBERS OR
305
TRICARE SELECT - RETIRED SPONSORS AND FAMILY MEMBERS OR
306
TRICARE SELECT - RESERVE SELECT SPONSORS AND FAMILY MEMBERS OR
307
TRICARE SELECT - RETIRED RESERVE SPONSORS AND FAMILY MEMBERS OR
308
TRICARE SELECT - YOUNG ADULT OR
409
TRS SURVIVOR CONTINUING INDIVIDUAL COVERAGE OR
410
TRS SURVIVOR CONTINUING FAMILY COVERAGE OR
411
TRS SURVIVOR NEW INDIVIDUAL COVERAGE OR
412
TRS SURVIVOR NEW FAMILY COVERAGE OR
413
TRS MEMBER-ONLY COVERAGE OR
414
TRS MEMBER AND FAMILY COVERAGE OR
418
TRR MEMBER-ONLY COVERAGE OR
419
TRR MEMBER AND FAMILY COVERAGE OR
420
TRR SURVIVOR INDIVIDUAL COVERAGE OR
421
TRR SURVIVOR FAMILY COVERAGE OR
422
TYA STANDARD FOR ADFMs OR
423
TYA STANDARD FOR RETIRED AND MOH FAMILY MEMBERS OR
424
TYA RESERVE SELECT OR
425
TYA RETIRED RESERVE OR
999
UNVERIFIED NEWBORN
OR ENROLLMENT/HEALTH PLAN CODE =
AS
TRICARE SELECT - ACTIVE DUTY SURVIVORS OR
AT
TRICARE SELECT - ACTIVE DUTY TRANSITIONAL SURVIVORS OR
GS
TRICARE SELECT - GUARD/RESERVE SURVIVORSOR
GT
TRICARE SELECT - GUARD/RESERVE TRANSITIONAL SURVIVORS
AND PATIENT ZIP CODE MUST =
PHL
PHILIPPINES
AND PROVIDER STATE OR COUNTRY CODE MUST =
PHL
PHILIPPINES
2-305-39R
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
AS
COMPREHENSIVE AUTISM CARE DEMONSTRATION
THEN PROCEDURE CODE MUST BE 0359T, 0360T, 0361T, 0364T, 0365T, 0368T, 0369T, 0370T, T1023, 97151, 97153, 97155, OR 97156
2-305-40R
IF BEGIN DATE OF CARE IS ≥ 01/01/2018
AND ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
R
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001
THEN ENROLLMENT/HEALTH PLAN CODE MUST =
U
TRICARE PRIME, CIVILIAN CARE OR
Z
TRICARE PRIME, MTF/eMSM/PCM OR
ME
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NETWORK OR
MS
MEDICARE/TRICARE DUAL ELIGIBLE UNDER 65/NON-NETWORK OR
WF
TPR FOR ENROLLMENT ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
ELEMENT NAME:  HEALTH CARE DELIVERY PROGRAM (HCDP) SPECIAL ENTITLEMENT CODE (2-306)
VALIDITY EDITS
2-306-01V
MUST BE A VALID HCDP SPECIAL ENTITLEMENT CODE (REFER TO Section 2.5)
Relational Edits
NONE
ELEMENT NAME:  CA/NAS NUMBER (2-310)
1  CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.
VALIDITY EDITS
2-310-01V
IF BEGIN DATE OF CARE ≥ 03/28/2013
THEN CA/NAS NUMBER MUST BE BLANK.
ELSE IF CA/NAS NUMBER IS NOT BLANK
THEN MUST BE 1 TO 11 OR 1 TO 15 ALPHANUMERIC CHARACTERS.
Relational Edits
NO ERROR
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN BYPASS ALL CA/NAS NUMBER RELATIONAL EDITING.
NO ERROR
IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS
THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA1
NO ERROR
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
R
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
PF
ECHO
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY OR
ST
SPECIALIZED TREATMENT OR
WR
MENTAL HEALTH WRAP AROUND
THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR
IF ENROLLMENT/HEALTH PLAN CODE =
U
TRICARE PRIME, CIVILIAN PCM OR
W
TPR SERVICE MEMBER - USA OR
X
FOREIGN SERVICE MEMBER OR
Y
CHCBP - NON-NETWORK OR
Z
TRICARE PRIME, MTF/eMSM/PCM OR
AA
CHCBP - NETWORK OR
BB
TSP OR
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK OR
PS
TSRx OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WF
TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR
IF HCC MEMBER CATEGORY CODE =
T
FOREIGN MILITARY MEMBER
THEN BYPASS ALL CA/NAS NUMBER EDITING.
NO ERROR
IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE =
15
PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
26
EXPENSES INCURRED PRIOR TO COVERAGE OR
27
EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
30
PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
31
CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
32
OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
33
CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
34
CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
62
PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
141
CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
THEN BYPASS ALL CA/NAS NUMBER EDITING
NO ERROR
IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS NUMBER EDITING.
2-310-02R
IF CA/NAS EXCEPTION REASON ≠ BLANK
THEN CA/NAS NUMBER MUST = BLANK
2-310-03R
•  MENTAL HEALTH CHECK
IF CA/NAS EXCEPTION REASON = BLANK
AND TYPE OF SERVICE (FIRST POSITION) =
I
INPATIENT
AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =
290-316 (MENTAL HEALTH, ICD-9-CM)
AND PATIENT ZIP CODE IS IN AN MTF/eMSM CATCHMENT AREA1
AND BEGIN DATE OF CARE IS < 03/28/2013
THEN CA/NAS NUMBER MUST BE CODED
UNLESS ANY OCCURRENCE OF OVERRIDE CODE =
C
GOOD FAITH PAYMENT
THEN CA/NAS NUMBER MUST = BLANK
2-310-04R
IF CA/NAS NUMBER IS CODED
THEN CA/NAS EXCEPTION REASON MUST = BLANK
ELEMENT NAME:  CA/NAS REASON FOR ISSUANCE (2-315)
VALIDITY EDITS
2-315-01V
IF BEGIN DATE OF CARE ≥ 03/28/2013
THEN CA/NAS REASON FOR ISSUANCE MUST BE BLANK.
ELSE VALUE MUST A VALID CA/NAS REASON FOR ISSUANCE.
Relational Edits
2-315-02R
IF CA/NAS NUMBER = BLANK
THEN CA/NAS REASON FOR ISSUANCE MUST = BLANK.
ELEMENT NAME:  CA/NAS EXCEPTION REASON (2-320)
1  CATCHMENT AREA DETERMINATION IS BASED ON BEGIN DATE OF CARE.
VALIDITY EDITS
2-320-01V
IF BEGIN DATE OF CARE ≥ 03/28/2013
THEN CA/NAS EXCEPTION REASON MUST BE BLANK.
ELSE VALUE MUST BE A VALID CA/NAS EXCEPTION REASON.
Relational Edits
NO ERROR
IF TYPE OF SUBMISSION =
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL
THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR
IF BEGIN DATE OF CARE IS OLDER THAN SIX YEARS
THEN DO NOT CHECK IF ZIP CODE IS IN CATCHMENT AREA
NO ERROR
IF ANY OCCURRENCE OF SPECIAL PROCESSING CODE =
R
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR-NOT A MEDICARE BENEFIT) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
AR
SHCP - MTF/eMSM REFERRED CARE OR
CE
SHCP - CCEP OR
PF
ECHO
RS
MEDICARE/TRICARE DUAL ENTITLEMENT (FIRST PAYOR-NO TRICARE PROVIDER CERTIFICATION, i.e., MEDICARE BENEFITS HAVE BEEN EXHAUSTED) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY OR
ST
SPECIALIZED TREATMENT OR
WR
MENTAL HEALTH WRAP AROUND
THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR
IF ENROLLMENT/HEALTH PLAN CODE =
U
TRICARE PRIME, CIVILIAN PCM OR
W
TPR SERVICE MEMBER - USA OR
X
FOREIGN SERVICE MEMBER OR
Y
CHCBP - NON-NETWORK OR
Z
TRICARE PRIME, MTF/eMSM/PCM OR
AA
CHCBP - NETWORK OR
BB
TSP OR
FE
TFL - NETWORK OR
FS
TFL - NON-NETWORK OR
PS
TSRx OR
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE OR
WF
TPR FOR ENROLLED ADFM RESIDING WITH A TPR ELIGIBLE SERVICE MEMBER
THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR
IF HCC MEMBER CATEGORY CODE =
T
FOREIGN MILITARY MEMBER
THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING.
NO ERROR
IF ANY OCCURRENCE OF ADJUSTMENT/DENIAL REASON CODE FOR THAT DETAIL OCCURRENCE =
15
PAYMENT ADJUSTED BECAUSE THE SUBMITTED AUTHORIZATION NUMBER IS MISSING, INVALID, OR DOES NOT APPLY TO THE BILLED SERVICES OR PROVIDER OR
26
EXPENSES INCURRED PRIOR TO COVERAGE OR
27
EXPENSES INCURRED AFTER COVERAGE TERMINATED OR
30
PAYMENT ADJUSTED BECAUSE THE PATIENT HAS NOT MET THE REQUIRED ELIGIBILITY, SPEND DOWN, WAITING, OR RESIDENCY REQUIREMENTS OR
31
CLAIM DENIED AS PATIENT CANNOT BE IDENTIFIED AS OUR INSURED OR
32
OUR RECORDS INDICATE THAT THIS DEPENDENT IS NOT AN ELIGIBLE DEPENDENT AS DEFINED OR
33
CLAIM DENIED. INSURED HAS NO DEPENDENT COVERAGE OR
34
CLAIM DENIED. INSURED HAS NO COVERAGE FOR NEWBORNS OR
62
PAYMENT DENIED/REDUCED FOR ABSENCE OF, OR EXCEEDED, PRE-CERTIFICATION/AUTHORIZATION OR
141
CLAIM ADJUSTMENT BECAUSE THE CLAIM SPANS ELIGIBLE AND INELIGIBLE PERIODS OF COVERAGE
THEN BYPASS ALL CA/NAS EXCEPTION REASON EDITING
NO ERROR
IF AMOUNT OF OTHER HEALTH INSURANCE PAID IS > ZERO
THEN NO CA/NAS IS REQUIRED -- BYPASS ALL CA/NAS EXCEPTION REASON EDITING
2-320-04R
IF PATIENT ZIP CODE IS IN AN MTF/eMSM CATCHMENT AREA1
AND TYPE OF SERVICE (FIRST POSITION) =
I
INPATIENT
AND PRINCIPAL TREATMENT DIAGNOSIS/POA INDICATOR (POSITIONS 1-7) =
290-316 (MENTAL HEALTH, ICD-9-CM)
AND CA/NAS NUMBER NOT CODED
AND BEGIN DATE OF CARE IS < 03/28/2013
THEN CA/NAS EXCEPTION REASON MUST BE CODED
ELEMENT NAME:  PRICING RATE CODE (2-325)
VALIDITY EDITS
2-325-01V
VALUE MUST A VALID NON-INSTITUTIONAL PRICING RATE CODE.
Relational Edits
2-325-01R
IF PRICING RATE CODE =
C
AMBULATORY SURGERY FACILITY PAYMENT RATE OR
D
DISCOUNTED AMBULATORY SURGERY FACILITY PAYMENT RATE OR
E
AMBULATORY SURGERY-PAID AS BILLED OR
P
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
Q
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, DISCOUNTED AMBULATORY SURGERY-FACILITY PAYMENT RATE OR
R
CLAIM AUDITING SOFTWARE-ADDED PROCEDURE, AMBULATORY SURGERY-PAID AS BILLED
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
16
AMBULATORY SURGERY FACILITY CHARGE
2-325-02R
IF ADJUSTMENT/DENIAL REASON CODE FOR THAT OCCURRENCE/LINE ITEM IS A CODE LISTED IN Addendum G, Figure 2.G-1.
THEN PRICING RATE CODE MUST =
0
PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS)
2-325-03R
IF PRICING RATE CODE FOR THAT OCCURRENCE/LINE ITEM =
0
PRICING NOT APPLICABLE (DENIED SERVICE/SUPPLIES AND ALLOWED DRUGS)
THEN AMOUNT ALLOWED BY PROCEDURE CODE MUST = ZERO
UNLESS TYPE OF SERVICE (SECOND POSITION) =
B
RETAIL DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS OR
M
MOP DRUGS, SUPPLIES, PRESCRIPTION AUTHORIZATIONS, AND REVIEWS
OR TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED RECORD (HCSR) DATA OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR)
2-325-04R
IF PRICING RATE CODE =
V
MEDICARE REIMBURSEMENT RATE
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
16
AMBULATORY SURGERY FACILITY CHARGE OR
T
MEDICARE/TRICARE DUAL ENTITLEMENT (SECOND PAYOR) AND BEGIN DATE OF CARE ≥ 10/01/2001 OR
FS
TFL (SECOND PAYOR) OR
MN
TSP - NON-NETWORK OR
MS
TSP - NETWORK
2-325-05R
IF PRICING RATE CODE =
U
SHCP CLAIM OR ACTIVE DUTY MEMBER TPR PAID OUTSIDE NORMAL LIMITS
THEN ONE OCCURRENCE OF SPECIAL PROCESSING CODE MUST =
AR
SHCP - MTF/eMSM REFERRED CARE OR
AN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
CE
SHCP - CCEP OR
GU
SERVICE MEMBER ENROLLED IN TPR OR
SC
SHCP - NON-TRICARE ELIGIBLE OR
SE
SHCP - TRICARE ELIGIBLE OR
SM
SHCP - EMERGENCY
OR ENROLLMENT/HEALTH PLAN CODE MUST =
SN
SHCP - NON-MTF/eMSM-REFERRED CARE OR
SR
SHCP - MTF/eMSM REFERRED CARE
2-325-06R
IF PRICING CODE =
W
PRICED OVER CMAC
AND ENROLLMENT/HEALTH PLAN CODE =
T
TRICARE STANDARD PROGRAM
AND AT LEAST ONE OCCURRENCE OF SPECIAL PROCESSING CODE =
NE
OPERATION NOBLE EAGLE/OPERATION ENDURING FREEDOM DEMONSTRATION
AND BEGIN DATE OF CARE ≥ 09/14/2001 AND < 11/01/2009
THEN PROVIDER PARTICIPATING INDICATOR MUST =
N
NO
2-325-08R
IF PRICING RATE CODE =
P1
OPPS OR
P2
OPPS WITH COST OUTLIER OR
P3
OPPS WITH DISCOUNT OR
P5
PARTIAL HOSPITALIZATION - PAID AS OPPS
THEN APC CODE MUST ≠ BLANK
2-325-09R
IF PRICING RATE CODE =
CA
CAH REIMBURSEMENT
THEN BEGIN DATE OF CARE MUST BE ≥ 12/01/2009
UNLESS PROVIDER STATE OR COUNTRY CODE =
AK
ALASKA
THEN BEGIN DATE OF CARE MUST BE ≥ 07/01/2007
ELEMENT NAME:  AMBULATORY PAYMENT CLASSIFICATION (APC) CODE (2-330)
VALIDITY EDITS
2-330-01V
MUST BE A VALID APC CODE AS LISTED ON DHA’S OPPS WEB SITE AT HTTP://HEALTH.MIL/MILITARY-HEALTH-TOPICS/BUSINESS-SUPPORT/RATES-AND-REIMBURSEMENT/OUTPATIENT-PROSPECTIVE-PAYMENT-SYSTEM, BLANK, OR ALL ZEROES
UNLESS AMOUNT ALLOWED BY PROCEDURE CODE = ZERO
Relational Edits
2-330-01R
IF APC CODE = BLANK
THEN PRICING RATE CODE ≠
P1
OPPS OR
P2
OPPS WITH COST OUTLIER OR
P3
OPPS WITH DISCOUNT OR
P5
PARTIAL HOSPITALIZATION - PAID AS OPPS
ELEMENT NAME:  OPPS PAYMENT STATUS INDICATOR CODE (2-331)
VALIDITY EDITS
2-331-01V
MUST BE A VALID OPPS PAYMENT STATUS INDICATOR CODE (REFER TO Section 2.6) OR BLANK.
Relational Edits
2-331-01R
IF OPPS PAYMENT STATUS INDICATOR CODE = BLANK
THEN APC CODE MUST = ALL ZEROES OR BLANK.
ELEMENT NAME:  AMOUNT NETWORK PROVIDER DISCOUNT (2-335)
VALIDITY EDITS
2-335-01V
MUST BE NUMERIC AND ≥ ZERO
Relational Edits
2-335-01R
IF TYPE OF SUBMISSION =
B
ADJUSTMENT TO NON-TED (HCSR) DATA OR
C
COMPLETE CANCELLATION OR
D
COMPLETE DENIAL OR
E
COMPLETE CANCELLATION OF NON-TED RECORD (HCSR) DATA OR
O
ZERO GOVERNMENT TED RECORD DUE TO 100% OHI
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
2-335-02R
IF PROVIDER NETWORK STATUS INDICATOR =
2
NON-NETWORK PROVIDER
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
2-335-03R
IF REGION INDICATOR =
b
BLANK
THEN AMOUNT NETWORK PROVIDER DISCOUNT MUST = ZERO
- END -

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